The aggressive agitated elderly patient

The alarm has gone off in the CDU toilet.  Inside the toilet was an 87 year old man in only his hospital issue paper y-fronts demanding someone call the police because he is being “held against his will”.  He is refusing to leave the toilet, refusing to let you switch off the godawful crash alarm.  One nurse is hanging for dear life on the other side of the door to keep it open.  2 other patients with dementia in the same bay keep on wandering past, wanting to “help”.

What is your approach to the agitated patient?

There are 2 arms to any case such as this, first off we have to ensure the safety of the patient, other patients in the vicinity, other staff, and ourselves.  The next thing we need to establish is why has this person become agitated?

Medical causes of potential agitation are wide and varied.  Delirium in itself should be thought of as a medical emergency, as it carries a potentially high mortality (though estimates vary hugely 20%-70%).

This mnemonic may help – “SHED WIMP HELPS”

Substances, Hypoxia, Events (vascular), Dehydration, Withdrawl, Infection, Myocardial Infarction, Psychiatric, Head Injury , Endocrine, Low BM,  Pain, Seizures.

The key information here is going to be what you glean from the ambulance record, and whoever normally looks after your patient.  Is their behaviour normal for them?  Is it out of character?  If you are seeing that patient for the first time in the ED you are in the best position to assess them, as very often family members, carers, and other information will be lost prior to the RMO’s clerking them on the medical ward 6 or 7 hour later (on a good day).  If they are more confused than normal this does need investigating.

So say we’ve established that the patient has dementia, that they are in CDU for some form of social care assessment, and that to all intense and purposes there is no medical problem.

The best way to nurse someone with delirium or dementia is to keep them in a brightly lit room, with visual cues as to where they are, and what time it is.  It’s important to have consistent contact with the same individuals, such as carers from a nursing home, or the same nurse.  It’s important that the environment is calm, quiet, and free of interruptions.  Try to make sure that the patient has access to their hearing aids, and glasses, to avoid sensory disturbances.  There should be easy access to food and drink.  If you were going to design an environment to provoke a patient with dementia into confusion and agitation you’d design a place pretty much like an emergency department.

It’s noisy, there is no consistency of staff, patients are moved often, there are often absolutely no visual cues as to what time of day or night it is, if there are clocks they are always wrong.  The trolleys or wheelchairs are not comfortable, there is often no access to food or drink.

If they’ve trapped themselves in the toilet, or a running around the ward trying to escape you might feel under pressure to try some medication.  For elderly patients with dementia most of the literature tends to recommend either haloperidol or midazolam, but there is very little good quality data for elderly patients.  There is a Cochrane review of both antipsychotics and benzodiazepines in depression, they conclude that there is no difference in efficacy between atypical and typical antipsychotics, but no evidence that benzos help with non-alcohol related delirium.  So be cautious with both, haloperidol is thought to be safer because it doesn’t cause as much respiratory depression. IV doses are safer and more predictable if you can get a line in.

IF you can’t get a line in, this is what I’d put in my dart gun, either of…

Haloperidol 1-5mg IM Avoid if QTc is prolonged (risk of Torsade)Risk of dystonic reaction
Midazolam 2.5mg IM Risk of respiratory depression

 

After some time using de-escalation techniques, offers of food, drink, escape, to downright begging, we tried some IM medication.  I got punched in the face giving our gentleman 2.5mg of IM haloperidol.  About 5 minutes later his daughter arrived.  She took one look at her dad held out her hand, sighed, said “come over here Dad”, her father immediately let himself out of the toilet, and came to his daughter’s outstretched hand.

As she walked him back to his bed I heard him say “Thank god you came, I don’t know why they were keeping my trapped in that loo”

I love my job.

 

Paediatric Gastroenteritis

vomitWarning.  This is occasionally devolves into a bit of a rant, however it’s a rant with a sound evidence base.

Can we please give kids with gastroenteritis some anti-emetic?  If you happen to be reading this in the US, Canada, New Zealand or Austrailia where standard practice is a little different, I apologise.  Let me give you some background.

In the UK children who get gastroenteritis and come to ED get assessed, usually because parents have been trying and failing to hydrate them.  We tend to give them an oral fluid challenge.  Usually ORS at 5 or 10mls ever 5 or 10 minutes.  They get a full history, examination, their hydration status is documented and usually we wait for them to urinate.  If they don’t vomit, urinate (and the urine dip is okay), we shout hurrah, fist bump (or would but we are British) and send the parent on their way with a prescription or advice to get or make ORS, and to continue with the little and often amount of fluid required.

If they ‘fail’ this challenge by vomiting we are often forced to admit them, and continue with the cycle until they wee.  Paediatric admission units have one or two of these children on the go at any one time, and we just keep ploughing on until the child stops vomiting, or they get dehydrated enough to require NG or IV fluid.

For some strange reasons in this group of patients there is a lot of resistance to trying an oral fluid challenge with an anti-emetic.

I have yet to hear a coherent reason as to why this but the commonest one is that it ‘might mask symptoms’.  I can’t understand why this could be the case, as anti-emetics work by blocking receptors in the CTZ.  I’m not sure how this would stop vomiting secondary to some other serious disease process.  If someone has a closed head injury like a subdural they are going to continue to vomit no matter what you do, and will have other signs.  Similarly if a child has a metabolic disorder, their BM is going to be low (or really ‘freakin’ high), or there are going to be other clues in the history.  Also I’m suggesting giving a dose of anti-emetic to kids that we have diagnosed with acute gastroenteritis, which implies that you have assessed the patient, taken a history and examined them.  The anti-emetic the literature seems to favour is ondansetron.

So will we miss something? 

Looking for evidence for this is tricky, as it’s hard to prove a negative, especially when the ‘things we might miss’ are very rare metabolic disorders.  There is some research that backs me up.

Sturm, Jesse J., et al. “Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses?.” Annals of emergency medicine 55.5 (2010): 415-422.

Sturm conducted a retrospective review of visits to paediatric EDs in Atlanta, USA, between 2005 and 2007.  34 117 charts were reviewed, and ondansetron was used for 19857 patients.  They found that there was no significant change in the diagnosis at discharge between children given ondansetron and those who weren’t, they were also less likely to be admitted.  Children who were given ondansetron were more likely to return, and then be readmitted, but the admission rate globally was less in the ondansetron group than the nothing group.

Okay so it means we probably won’t miss anything but does it actually work?

YES. – NNT is about 5. That’s better than steroids in COPD (NNT 10) and Aspirin in STEMI (NNT 42).

Well the key single RCT was published in the NEJM in 2006, this was a prospective, double blind randomized controlled trial.

P 215 children 6 month – 10 years in the Paeds ED with gastroenteritis AND mild dehydration.
I 1 single dose of orally disintegrating ondansetron
C Placebo RESULTS
O Primary:Proportion who vomiting while having rehydration

Secondary:

  1. Number of vomits,
  2. Incidence of IV rehydration
  3. Admission rates.
Primary:14% vs 35% RR 0.4 95% CI 0.26-0.61

Secondary:

  1.  0.18 mean vomits Vs 0.65 p<0.0001
  2. 14 % Vs 31% RR 0.46 CI 0.26-0.79 p=0.003
  3. 4% Vs 5% not significant

 

You can get the study here.

What do these results mean?  Well it looks like the group that were given a single dose of ondansetron we more likely to pass their fluid challenge, less likely to need IV therapy, but were not necessarily more likely to go home.  I like this last result.  I think it means that if a child was still dehydrated, and needed further observation that this was what was happening rather than taking false reassurance from being given a medication.

Children were given 2mg PO ondansetron 8-15kg, 4mg 15-30kg, 8mg if >30kg.

Caveats?  The children participating in the study were assigned a dehydration score by a single rater, which was based on largely clinical, and subjective measures such as skin turgor.  The dehydration score they used is pretty much the same table as exists in paeds textbooks and APLS manuals so seems a reasonable method to use however, it does introduce the potential for bias.  The other concern for me about this study was the number of patients that were excluded prior to randomization, 3067 children were considered but only 243 were asked to enrol, another potential source for bias.

This study on it’s own yields a NNT of 5.  We need to treat 5 children with acute gastroenteritis with ondansetron to stop 1 kid vomiting.

This is all very promising but is there any other data to support it’s use?

I’m glad you asked….

Then a Cochrane review was published in the BMJ in 2012 which looked at the literature from 1980 to 2012.  Ondansetron They found 10 studies and compared ondansetron (oral, and IV) to granestron, dexamethasone, and other antiemetics.  They looked at ondansetron vs placebo for cessation of vomiting, initiation of IV rehydration and hospital admission rates.  Now the review could only find 4 studies looking at the effectiveness of PO Ondansetron vs placebo, but their headline result for cessation of vomiting was RR 1.44 95% CI 1.29-1.61 NNT = 4.  One study was reliable but VERY pro ondansetron and threw the results out a bit, but with that excluded you still got an impress result RR 1.33 9%% CI 1.19- 1.49 NNT =5.  There was no statistically significant difference in hospitalization rates within 72 hours, suggesting that children’s admission might be delayed rather than avoided if you trial them ondansetron.  They did manage to find a reduction in resorting to IV rehydration [RR 0.57 NNT 6].

SO there is good evidence to suggest that it is safe and effective to use oral ondansetron in a vomiting child with gastroenteritis, we will probably decrease length of stay, increase success of oral rehydration, and maybe save some money for the trust.  No one will thank you for it though…

…apart from the kid’s parent, oh and the kid.

Rant ends.

 

References

  • Carter, Ben, and Zbys Fedorowicz. “Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework.” BMJ open2.4 (2012).
  • Sturm, Jesse J., et al. “Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses?.” Annals of emergency medicine 55.5 (2010): 415-422.
  • Freedman, Stephen B., et al. “Oral ondansetron for gastroenteritis in a pediatric emergency department